Hemorrhagic Malignant Pleural Effusion: Diagnosis, Survival Rate, and Response to Talc Pleurodesis.

Hemorrhagic malignant pleural effusion (HMPE) is diagnosed in 47-50% of all malignant pleural effusions (MPE). The aim of this study is to evaluate clinical, radiological, and morphological manifestations of HMPE and results of talc pleurodesis treatment. This is a retrospective review of the medical charts of 135 MPE patients which consists of HMPE group (42 patients) and simple MPE group (63 patients) (median age 67.9 years; 43 males, 62 females). In HMPE vs. simple MPE patients, pronounced dyspnea (100% vs. 88.9%, P = 0.024), chest pain (59.5% vs. 60.3%, P = 1), general deterioration (78.6% vs. 74.6%, P = 0.411) combined with large pleural effusion (81% vs. 50.8%, P = 0.001), and thickening of parietal pleura (73.8% vs. 68.3%, P = 0.349), all were more specific for HMPE. Cytological examination of HMPE showed more malignant pleural fluid cells (81% vs. 63.5%, P = 0.043). Histological examination revealed poorly differentiated types of tumors in 69.05% of HMPE (bronchogenic 33.33%, intestinal 16.67%, breast 14.3%) vs. 7.94% of simple MPE. In 19 HMPE vs. 0 simple MPE patients, thoracoscopy showed bleeding nodules (94.7%) on thickened parietal pleura (84.2%). Pleurodesis with talc by slurry (59%) and poudrage (41%) was less effective in HMPE than in simple MPE patients after 1 month (failed response; 33.3% vs. 21.6, P = 0.019), 3 months (42.9% vs. 25.7%, P = 0.017), and 6 months (42.9% vs. 21.7%, P = 0.035). Survival in HMPE was significantly lower (3.06 months vs. 5.37 months, P = 0.0005). HMPE has more severe clinical, laboratory, radiological, and endoscopic manifestations due to a more poorly differentiated malignant process. Talc pleurodesis was less effective in HMPE, and survival was poor.

Cognitive and physical performance are well preserved following standard blood donation: A noninferiority, randomized clinical trial.

BACKGROUND: A walking blood bank (WBB) refers to the use of fellow combatants for battlefield blood donation. This requires pretesting combatants for infectious diseases and blood type. A fundamental prerequisite for this technique is that the donating soldier will suffer minimal physiological and mental impact. The purpose of the current study is to assess the effect of blood shedding on battlefield performance. METHODS: This is a double-blind randomized control trial. Forty Israel Defense Forces combatants volunteered for the study. Participants underwent baseline evaluation, including repeated measurement of vital signs, cognitive evaluation, physical evaluation, and a strenuous shooting test. Three weeks after the baseline evaluation, subjects were randomized to either blood donation or the control group. For blinding purposes, all subjects underwent venous catheterization for the duration of a blood donation. Repeated vital signs and function evaluation were then performed. RESULTS: Thirty-six patients were available for randomization. Baseline measurements were similar for both groups. Mean strenuous shooting score was 80.5 ± 9.5 for the control group and 82 ± 6.6 for the test group (p = 0.58). No clinically or statistically significant differences were found in tests designed to evaluate cognitive performance or physical functions. Vital signs taken multiple times were also similar between the test and control groups. CONCLUSIONS: Executive, cognitive, and physical functions were well preserved after blood donation. This study supports the hypothesis that a WBB does not decrease donor combat performance. The categorical prohibition of physical exercise following blood donation might need to be reconsidered in both military and civilian populations.

Reevaluating the selection process for the Israeli Defense Force's paramedic training program.

BACKGROUND: Selecting candidates for medical training programs is a complicated process aimed at identifying specific personal competencies, in an attempt to minimize attrition and produce better medical providers. The objective of this study was to evaluate the accuracy of the selection process for the Israeli Defense Force's paramedic training program and its ability to predict success measured at different end points. METHODS: Selection process test scores were crossed and measured against three different end points: attrition, national certification test scores, and training program graduation scores. RESULTS: Data were available for 146 candidates. A positive association was detected between lower formulated selection scores and attrition rates (p<0.01). Out of the 11 tests conducted that comprise the final selection score, two had shown significant association with attrition. The calculated score of these specific two tests was found to have similar association with attrition as the formulated selection score. CONCLUSIONS: The current Israeli Defense Force's paramedic-formulated selection score has shown association with attrition; candidates performing poorly throughout the selection process were less likely to complete training. Similar results may be achieved by implementing a more efficient selection process based on fewer tests. Further studies are required to identify the optimal composition for selection processes. Ongoing learning and research form the ground for improvement, not only of trauma medicine but of all aspects of medicine.

The Israeli Defense Force experience with intraosseous access.

INTRODUCTION: Obtaining vascular access is of paramount importance in trauma care. When peripheral venous access is indicated but cannot be obtained, the intraosseous route represents an alternative. The Bone Injection Gun (BIG) is the device used for intraosseous access by the Israeli Defense Force (IDF). The purpose of this study is to assess the success rate of intraosseous access using this device. METHOD: The IDF Trauma Registry from 1999 to 2012 was searched for patients for whom at least 1 attempt at intraosseous access was made. RESULTS: 37 attempts at intraosseous access were identified in 30 patients. Overall success rate was 50%. No differences in success rates were identified between different care givers. Overall mortality was 87%. CONCLUSION: The use of BIG in the IDF was associated with a low success rate at obtaining intraosseous access. Although inability to achieve peripheral venous access can be considered an indicator for poor prognosis, the high mortality rate for patients treated with BIG can also stand for the provider's low confidence in using this tool, making its use a last resort. This study serves as an example to ongoing learning process that includes data collection, analysis, and improvement, constantly taking place in the IDF.

The value of noninvasive measurement of the compensatory reserve index in monitoring and triage of patients experiencing minimal blood loss.

Currently available triage and monitoring tools are often late to detect life-threatening clinically significant physiological aberrations and provide limited data in prioritizing bleeding patients for treatment and evacuation. The Compensatory Reserve Index (CRI) is a novel means of assessing physiologic reserve, shown to correlate with central blood volume loss under laboratory conditions. The purpose of this study was to compare the noninvasive CRI device with currently available vital signs in detecting blood loss. Study subjects were soldiers volunteering for blood donation (n = 230), and the control group was composed of soldiers who did not donate blood (n = 34). Data collected before and after blood donation were compared, receiver operator characteristic curves were generated after either donation or the appropriate time interval, and areas under the curves (AUCs) were compared. Compared with pre-blood loss, blood donation resulted in a mean reduction of systolic blood pressure by 3% (before, 123 mmHg; after, 119 mmHg; P < 0.01). The CRI demonstrated a 16% reduction (before, 0.74; after, 0.62; P < 0.01). Heart rate, diastolic blood pressure, and oxygen saturation remained unchanged. The AUC for change in CRI was 0.81, 0.56 for change in heart rate, 0.53 for change in systolic blood pressure, 0.55 and 0.58 for pulse pressure and shock index, respectively. The AUCs for detecting mild blood loss at a single measurement were 0.73 for heart rate, 0.60 for systolic blood pressure, 0.62 for diastolic blood pressure, 0.45 for pulse oximetry, and 0.84 for CRI. The CRI was better than standard indices in detecting mild blood loss. Single measurement of CRI may enable a more accurate triage, and CRI monitoring may allow for earlier detection of casualty deterioration.

Something's missing: peripheral intravenous catheter fracture.

We describe a case of peripheral intravenous catheter fracture occurring during a routine training exercise. The supervising instructor immediately placed a venous tourniquet proximal to the insertion site and urgently transported the patient to the hospital. The missing catheter segment was identified within the median cubital vein under ultrasonography and was removed by venous cutdown under local anesthesia. An investigation determined that reinsertion of the needle into the advanced catheter likely caused the fracture and that application of a tourniquet may have prevented embolism of the fractured segment. Our literature review suggested that peripheral intravenous catheter fracture is likely vastly underreported, with only one prior case identified in the English literature. Action was taken following the event to educate all Israeli Defense Force medical providers regarding both proper preventive measures and recognition and treatment of catheter fracture should it occur. This case highlights the importance of health care providers being aware of the possibility of catheter fracture, as well as steps to take to prevent and mitigate its occurrence.

Blood glucose levels as an adjunct for prehospital field triage.

OBJECTIVE: Elevated blood glucose levels (BGL) are known to be part of the physiologic response to stress following physical trauma. We aimed to study whether a measured BGL might help improve accuracy of field triage. METHODS: We conducted a retrospective study using the Israel Defense Forces Trauma Registry. BGLs were determined upon hospital arrival and were not available to medical providers in the field. RESULTS: There were 706 casualties in the registry who had a recorded BGL upon hospital arrival. Sixty percent (18/30) of casualties who had a BGL ≥200 mg/dL had been triaged in the field as severely wounded, whereas 11% (71/651) of casualties who had a BGL <200 mg/dL had been triaged as severely wounded. For predicting an Injury Severity Score >15, the positive likelihood ratio using field triage of severe was 11, using BGL ≥200 mg/dL was 8, and using a combination of the two tests was 26. For predicting the need for intensive care unit (ICU) admission, the ratios were 8, 13, and 23, respectively. CONCLUSIONS: Elevated BGL improved prediction of high Injury Severity Score and ICU use among casualties triaged as severe. If future research using BGL measured in the field yields similar results, combining BGL with standard field triage may allow for more accurate identification of casualties who need acute field intervention, have major injury, or require ICU admission.

Training modalities and self-confidence building in performance of life-saving procedures.

OBJECTIVE: Physicians and paramedics in the Israel Defense Forces are trained to perform advanced medical procedures using standardized training modalities, such as manikins. We studied the association of experience using these training modalities with self-reported confidence in procedure performance. METHODS: Providers were sent a questionnaire regarding their experience with and self-confidence levels for performing endotracheal intubation, cricothyroidotomy, needle chest decompression, tube thoracostomy, and intraosseous infusion. RESULTS: Provider level (physician or paramedic) and gender were associated with reported self-confidence levels. Manikin and supervised and unsupervised patient experience exhibited positive associations with self-confidence, but (animal) model experience did not. For many procedure-training modality pairs, we identified a plateau level above which additional experience was minimally associated with an increase in self-confidence. CONCLUSIONS: Among military advanced life support providers, self-confidence levels in procedure performance are positively associated with experience gained from manikins and supervised and unsupervised patient application. We were not able to demonstrate a clear benefit of an animal model in increasing self-confidence. A plateau was generally identified, indicating decreased benefit from the use of a particular training modality for a particular procedure. Modifying training regimens in light of these findings may help maximize the self-confidence of advanced life support providers more efficiently.